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80–393 PDF 2013

EXAMINING THE APPROPRIATENESS OF STANDARDS FOR MEDICAL IMAGING AND RADIATION 

THERAPY TECHNOLOGISTS 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED TWELFTH CONGRESS 

SECOND SESSION 

JUNE 8, 2012 

Serial No. 112–150 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 

COMMITTEE ON ENERGY AND COMMERCE 

FRED UPTON, Michigan 

Chairman 

JOE BARTON, Texas 

Chairman Emeritus 

CLIFF STEARNS, Florida 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

JOSEPH R. PITTS, Pennsylvania 

MARY BONO MACK, California 

GREG WALDEN, Oregon 

LEE TERRY, Nebraska 

MIKE ROGERS, Michigan 

SUE WILKINS MYRICK, North Carolina 

Vice Chairman 

JOHN SULLIVAN, Oklahoma 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

BRIAN P. BILBRAY, California 

CHARLES F. BASS, New Hampshire 

PHIL GINGREY, Georgia 

STEVE SCALISE, Louisiana 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

GREGG HARPER, Mississippi 

LEONARD LANCE, New Jersey 

BILL CASSIDY, Louisiana 

BRETT GUTHRIE, Kentucky 

PETE OLSON, Texas 

DAVID B. MCKINLEY, West Virginia 

CORY GARDNER, Colorado 

MIKE POMPEO, Kansas 

ADAM KINZINGER, Illinois 

H. MORGAN GRIFFITH, Virginia 

HENRY A. WAXMAN, California 

Ranking Member 

JOHN D. DINGELL, Michigan 

Chairman Emeritus 

EDWARD J. MARKEY, Massachusetts 

EDOLPHUS TOWNS, New York 

FRANK PALLONE, JR., New Jersey 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

LOIS CAPPS, California 

MICHAEL F. DOYLE, Pennsylvania 

JANICE D. SCHAKOWSKY, Illinois 

CHARLES A. GONZALEZ, Texas 

TAMMY BALDWIN, Wisconsin 

MIKE ROSS, Arkansas 

JIM MATHESON, Utah 

G.K. BUTTERFIELD, North Carolina 

JOHN BARROW, Georgia 

DORIS O. MATSUI, California 

DONNA M. CHRISTENSEN, Virgin Islands 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

SUBCOMMITTEE ON HEALTH

JOSEPH R. PITTS, Pennsylvania 

Chairman 

MICHAEL C. BURGESS, Texas 

Vice Chairman 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

MIKE ROGERS, Michigan 

SUE WILKINS MYRICK, North Carolina 

TIM MURPHY, Pennsylvania 

MARSHA BLACKBURN, Tennessee 

PHIL GINGREY, Georgia 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

LEONARD LANCE, New Jersey 

BILL CASSIDY, Louisiana 

BRETT GUTHRIE, Kentucky 

JOE BARTON, Texas 

FRED UPTON, Michigan (ex officio) 

FRANK PALLONE, JR., New Jersey 

Ranking Member 

JOHN D. DINGELL, Michigan 

EDOLPHUS TOWNS, New York 

ELIOT L. ENGEL, New York 

LOIS CAPPS, California 

JANICE D. SCHAKOWSKY, Illinois 

CHARLES A. GONZALEZ, Texas 

TAMMY BALDWIN, Wisconsin 

MIKE ROSS, Arkansas 

ANTHONY D. WEINER, New York 

JIM MATHESON, Utah 

HENRY A. WAXMAN, California (ex officio) 

(II) 

(III) 

C O N T E N T S 

Page 

Hon. Joseph R. Pitts, a Representative in Congress from the Commonwealth 

of Pennsylvania, opening statement ................................................................... 1 

Prepared statement .......................................................................................... 3 

Hon. Ed Whitfield, a Representative in Congress from the Commonwealth 

of Kentucky, opening statement ......................................................................... 4 

Hon. Michael C. Burgess, a Representative in Congress from the State of 

Texas, opening statement .................................................................................... 4 

Hon. Frank Pallone, Jr., a Representative in Congress from the State of 

New Jersey, opening statement .......................................................................... 5 

Hon. John Barrow, a Representative in Congress from the State of Georgia, 

opening statement ................................................................................................ 6 

Hon. Henry A. Waxman, a Representative in Congress from the State of 

California, opening statement ............................................................................. 6 

WITNESSES

John Spiegel, Director, Medicare Program Integrity Council, Center on Program Integrity, Centers for Medicare and Medicaid Services, Department 

of Health and Human Services ........................................................................... 36 

Prepared statement .......................................................................................... 39 

Leonard Gunderson, Chairman, Board of Directors, American Society for Radiation Oncology ................................................................................................... 45 

Prepared statement .......................................................................................... 47 

Rebecca Smith-Bindman, Professor of Radiology, Epidemiology/Biostatistics, 

Obstetrics, Gynecology, and Reproductive Sciences, University of California, 

San Francisco School of Medicine ....................................................................... 57 

Prepared statement .......................................................................................... 60 

Sal Martino, Chief Executive Officer, American Society of Radiologic Technologies ................................................................................................................. 74 

Prepared statement .......................................................................................... 76 

SUBMITTED MATERIAL

Statement, dated June 8, 2012, of Lynne Roy, Chair, Scope of Practice Task 

Force, Society of Nuclear Medicine Technologist Section, submitted by Mr. 

Pitts ....................................................................................................................... 8 

Statement, dated June 8, 2012, of American College of Radiology, submitted 

by Mr. Pitts ........................................................................................................... 14 

Letter, dated June 7, 2012, of John J. Mahmarian, President, American 

Society of Nuclear Cardiology, to Mr. Pitts, submitted by Mr. Pitts ............... 21 

Letter, dated June 23, 2009, of David W. Parke II, Executive Vice President, 

American Academy of Ophthalmology, to Senate Finance Committee members, submitted by Mr. Pitts ............................................................................... 23 

Statement, dated June 8, 2012, of Gary A. Ezzell, President, American Association of Physicists in Medicine, submitted by Mr. Pitts ................................ 25 

Statement, dated June 8, 2012, of Medical Imaging & Technology Alliance, 

submitted by Mr. Pitts ......................................................................................... 29 

Statement, dated June 8, 2012, of Donald Haydon, Chief Executive Officer, 

Society of Diagnostic Medical Sonography, submitted by Mr. Pitts ................ 32 

(1) 

EXAMINING THE APPROPRIATENESS OF 

STANDARDS FOR MEDICAL IMAGING AND 

RADIATION THERAPY TECHNOLOGISTS 

FRIDAY, JUNE 8, 2012 

HOUSE OF REPRESENTATIVES, 

SUBCOMMITTEE ON HEALTH, 

COMMITTEE ON ENERGY AND COMMERCE, 

Washington, DC. 

The subcommittee met, pursuant to call, at 10 a.m., in room 

2322, Rayburn House Office Building, Hon. Joseph R. Pitts (chairman of the subcommittee) presiding. 

Members present: Representatives Pitts, Burgess, Whitfield, 

Blackburn, Latta, Lance, Guthrie, Pallone, Engel, and Waxman (ex 

officio). 

Also present: Representative Barrow. 

Staff present: Andy Duberstein, Deputy Press Secretary; Ryan 

Long, Chief Counsel, Health; Katie Novaria, Legislative Clerk; 

John O’Shea, Senior Health Policy Advisor; Chris Sarley, Policy Coordinator, Environment and Economy; Heidi Stirrup, Health Policy 

Coordinator; Alli Corr, Democratic Policy Analyst; Amy Hall, 

Democratic Senior Professional Staff Member; and Anne Morris 

Reid, Democratic Professional Staff Member. 

Mr. PITTS. The subcommittee will come to order. The Chair recognizes himself for 5 minutes for an opening statement. 

OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN CONGRESS FROM THE COMMONWEALTH 

OF PENNSYLVANIA 

Today we are addressing the quality of medical imaging and radiation therapy services and their impact on patient safety and 

cost. I am sure that many people would be surprised to learn that 

there are no uniform licensure standards for the technologists who 

perform tests such as MRIs and CT scans every day in our country. 

Currently radiologic technicians are regulated at the State level 

and those standards can vary widely between States, from those 

with stringent standards to those that do not regulate the education or competency of these medical professionals at all. Patient 

safety can be impacted by improper positioning or poor technique 

by the technician, which can lead to misreading of scans and a 

need for duplicate tests. These tests cost Medicare billions of dollars every year, and we cannot afford to pay for multiple tests that 

should have been done right the first time. 

2 

I am a firm supporter of a bill by our colleague Ed Whitfield, 

H.R. 2104, the Consistency, Accuracy, Responsibility, and Excellence in Medical Imaging and Radiation Therapy Act, or the CARE 

Act. This commonsense bill enjoys bipartisan support and has been 

the subject of three hearings in this subcommittee over the last few 

years. 

It would direct the Secretary of HHS to, one, establish minimum 

standards for personnel who perform, plan, evaluate, or verify patient dose for medical imaging examinations or radiation therapy 

procedures; two, establish a program for designating certification 

organizations after consideration of specified criteria; three, provide 

a process for the certification of individuals whose training or experience are determined to be equal to or in excess of those of a graduate of an accredited educational program; and fourthly, publish a 

list of approved accrediting bodies for such certification organizations. Medicare reimbursement will be contingent on meeting the 

minimum training standards. 

I know that we have witnesses representing imaging and 

radiologic technicians here with us today. And I look forward to 

their insight and expertise in this area and their thoughts on the 

CARE Act. I would like to thank all of our witnesses for being here, 

and I look forward to your testimony. And at this time I yield to 

the gentleman Mr. Whitfield. 

[The prepared statement of Mr. Pitts follows:] 

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OPENING STATEMENT OF HON. ED WHITFIELD, A REPRESENTATIVE IN CONGRESS FROM THE COMMONWEALTH OF KENTUCKY 

Mr. WHITFIELD. Thank you very much, Mr. Chairman. I genuinely appreciate you and Ranking Member Pallone working with us 

on this important legislation. I certainly want to thank Mr. Barrow 

who is a cosponsor of this legislation, a lead cosponsor of this legislation. 

All of this started—at least for me—a couple of years ago, I guess 

in 2010, when we had a hearing and we had some people here involved in linear accelerators, and there was a case up in New York 

where the patient was severely burned. And as a result of that 

hearing, it came to our attention—although I am sure people like 

Dr. Gunderson and Dr. Martino knew this already—but it was 

quite obvious that all States do not require licensing for these technologists. And those States that do, frequently the standards are 

quite different. 

So the purpose of this legislation is simply to ensure that patients undergoing imaging or radiation therapy can feel comfortable that the personnel performing those procedures are qualified to do so. We have approximately 130 cosponsors of this legislation, and I think it is an important piece of legislation. And, hopefully, I look forward to working with all of the members of this subcommittee and the full committee to try to get this legislation to 

the floor as soon as we possibly can. Thank you. 

Mr. PITTS. I will yield the remainder of the time to the vice 

chairman, Dr. Burgess. 

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Mr. BURGESS. I thank the chairman for yielding. Both radiation 

therapy and medical imaging are important. Critical medical advancements, when used properly, save lives and should be used 

only when necessary and utilized properly to employ the safe use 

of radiation. 

That is kind of where the similarities end. Radiation therapy is 

just that. It is a treatment. Imaging is a screening tool. It is the 

difference between taking a picture and doing an operation. With 

medical imaging our goal, the goal should be to employ the lowest 

radiation while achieving the clearest picture. The therapy is to 

employ the most concentrated dose and achieve the goal of killing 

the tumor. 

With imaging radiation as a secondary thought, well, with therapy it is actually the tool that is used. In developing this—looking 

at our file cabinet under ‘‘R’’ and pull up the first two things that 

contain radiation and trying to lump them together may not be in 

the best interest, but there is no question that they both need to 

be properly utilized. 

Once again our approach is to two very different areas to address 

different issues. Certainly we should do everything in our power to 

make certain that providers, whether that be hospitals or doctors, 

reduce redundancy and only take an image one time if indeed only 

one image is indeed necessary. The creation of radiation benefit 

5 

managers is something that concerns me and it is a clear way to 

achieve denial of service rather than enhancement of service. 

On the therapy side, we need to look at the improved technological safeguards, increase medical education, specialty society accreditation, as was mentioned by the chairman, and coordination of 

medical professionals. 

Mr. Chairman, I thank you for the consideration. And I will yield 

back the balance of my time. 

Mr. PITTS. The Chair thanks the gentleman. 

I now yield to the ranking member, Mr. Pallone, for 5 minutes 

for an opening statement. 

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY 

Mr. PALLONE. Thank you Chairman Pitts. Today the subcommittee is meeting to discuss the appropriateness of standards 

for medical imaging and radiation therapy technologists. I am glad 

that we are having this hearing because it is an important patient 

safety issue. 

When I was the chairman, we held a hearing on the overview of 

medical radiation, and Mr. Whitfield talked about it. And that was 

in response to a series of alarming reports in The New York Times 

on medical radiation errors. Those stories raised red flags, and I 

felt it was important that members have an opportunity to better 

understand the landscape. What we learned at that hearing was 

critically important in that there were gaps in the oversight of certification and licensing of allied health professionals. We also determined, however, that radiation undoubtedly saves lives because it 

has reshaped the world of diagnostics and has offered patients less 

invasive alternatives for treating complex and life-threatening conditions. 

In addition, a direct result of the examination of this subcommittee has led to a number of efforts underway within the imaging field. In 2010 the FDA launched the initiative to reduce unnecessary radiation exposure for medical imaging, and working 

with manufacturers to improve the safety of imaging equipment 

through its regulation authority. 

In addition, in 2010, through the Medical Imaging & Technology 

Alliance, or MITA, manufacturers developed the CT dose check 

standard which includes features that assist an imaging team in 

providing better care. In addition, MITA is currently finalizing the 

CT access control standard which will produce an extra safeguard 

that will ensure only an authorized operator can alter the controls 

of a CT scanner. These efforts are commendable and should continue and be expanded. 

But there is clearly still work to be done to better ensure that 

the driving factors of why things go wrong are rectified. One issue 

that still remains is licensure and certification. While advancements in the industry become more complex and complicated to operate, in many States, individuals who operate these devices do not 

need to be licensed and are, therefore, not regulated at all in terms 

of education and expertise. Even in States where there are licensVerDate Aug 31 2005 08:57 Nov 25, 2013 Jkt 037690 PO 00000 Frm 00009 Fmt 6633 Sfmt 6633 F:\112-15~1\112-15~1 WAYNE
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ing requirements, the requirements are weak and not enforced. 

And I just don’t think that is acceptable. 

So that is why Representatives Whitfield and Barrow have introduced the CARE Act, a bill that would establish standards for the 

personnel who perform medical imaging examinations or radiation 

therapy procedures. This seems like commonsense policy and a legitimate first step in addressing radiation safety. And I hope that 

the subcommittee will consider that bill in the near future, Mr. 

Chairman. 

What we also know is that we have no idea how often errors 

occur and have no good data on where the weaknesses in the system truly are. So I do think there is a need to find ways to ensure 

that patients do not receive radiation doses in excess of recommended levels. I look forward, Mr. Chairman, to hearing from 

all our witnesses. We appreciate your taking the time to speak to 

the subcommittee on this very important issue. 

And I would like to yield the remainder of my time to the gentleman from Georgia who is the Democratic sponsor of the legislation, the CARE Act. 

OPENING STATEMENT OF HON. JOHN BARROW, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF GEORGIA 

Mr. BARROW. I thank the chairman and I thank Chairman Pitts 

and especially Chairman Whitfield for his leadership on this issue. 

I am glad we are having this hearing to shine a light on the fact 

that not all the folks performing radiation diagnostics and treatment are properly trained. Many people I represent are shocked to 

hear that. They know that it is a direct threat to public health 

when radiation technology is misapplied, and it is also an economic 

problem because of the direct and indirect costs of poor image quality. 

Along with Chairman Whitfield, I am the lead cosponsor of the 

CARE Act which will address this issue by requiring a standardized certification process for radiologic technologists. I think that is 

common sense, and I hope and expect it would be the consensus 

and position of this committee. I look forward to hearing from the 

witnesses and hopefully to moving this bill forward. With that, Mr. 

Chairman, I yield back the balance of my time. 

Mr. PITTS. The Chair recognizes the ranking member of the full 

committee, Mr. Waxman, for 5 minutes. 

OPENING STATEMENT OF HON. HENRY A. WAXMAN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA 

Mr. WAXMAN. Thank you very much, Mr. Chairman. The focus 

of today’s hearing, the accreditation of medical imaging and radiation therapy technologists, suggests that the certification process 

is key to maximizing patient safety when radiation delivery is involved. Accreditation of personnel may be an important component 

of patient safety, but as we learned at this subcommittee’s hearing 

on medical radiation in the last Congress it is not the silver bullet. 

Let me be clear at the outset: Diagnostic and therapeutic radiology interventions save lives and improve health outcomes. They 

are important procedures in our medical toolbox that unquestionVerDate Aug 31 2005 08:57 Nov 25, 2013 Jkt 037690 PO 00000 Frm 00010 Fmt 6633 Sfmt 6633 F:\112-15~1\112-15~1 WAYNE
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ably have made our health-care system better. CT scans minimize 

the need for exploratory surgery. Radiation therapy aids in the 

treatment of other breast and other forms of cancer. Even the basic 

X-ray plays a critical role in modern medicine. But with this technology comes an important obligation: making these interventions 

as safe as possible. Of course that includes qualified technologists, 

but it also means the delivery of the right procedure at the right 

time and with an appropriate dose of radiation. Patients are entitled to nothing less. 

Since we last met on this topic, there have been some notable advances in the public and private sectors alike. Consider the following: CMS has developed an accreditation process for physicians 

and other nonhospital providers who bill Medicare for advanced imaging services. The FDA has launched an initiative to reduce unnecessary radiation exposure in medical imaging. And several professional societies are working to communicate best practices to 

health professionals and patients and to begin to capture data on 

the amount of radiation patients are receiving. 

These efforts should be commended and continue to move forward, yet deficiencies still exist. We find only a patchwork of State 

regulation for the technologists who position patients and deliver 

radiation doses. And far too many patients continue to receive radiation doses in excess of recommended levels. 

Today’s hearing will examine all of this, hopefully with an eye 

on the ultimate prize: ensuring that all medical radiation services 

are designed, delivered, and monitored with the highest quality of 

care. I look forward to hearing from our witnesses this morning 

and I thank each of you in advance for your testimony. Thank you, 

Mr. Chairman. 

Mr. PITTS. The Chair thanks the gentleman. 

That concludes opening statements for the members. The Chair 

requests unanimous consent the following statements be introduced 

into the record: a statement of the Society of Nuclear Medicine 

Technologists section; a statement of the American College of Radiology; a statement by the American Society of Nuclear Cardiology; 

a statement of the American Academy of Ophthalmology; a statement of the American Association of Physicists in Medicine; a 

statement of the Medical Imaging & Technology Alliance; and a 

statement of the Society of Diagnostic Medical Sonography. Without objection, so ordered. 

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Mr. PITTS. I will introduce the panel at this time. 

Today’s witnesses are Mr. John Spiegel, who is the director of 

the Medicare Program Integrity Group at the Centers for Medicare 

and Medicaid Services, United States Department of Health and 

Human Services; Dr. Leonard Gunderson, chairman of the board of 

directors for the American Society for Radiation Oncology, and 

emeritus professor and consultant in radiation oncology at the 

Mayo Clinic; Dr. Rebecca Smith-Bindman is a professor in the departments of radiology and biomedical imaging, epidemiology and 

biostatistics and obstetrics, gynecology, and reproductive sciences 

at the University of California San Francisco; and Dr. Salvatore 

Martino is a registered radiologic technologist and is the chief executive officer for the American Society of Radiologic Technologists. 

We are happy to have all of you with us today. Your written 

statements will be made part of the record. And at this time you 

are recognized for 5 minutes each to summarize your testimony. 

STATEMENTS OF JOHN SPIEGEL, DIRECTOR, MEDICARE PROGRAM INTEGRITY GROUP, CENTER ON PROGRAM INTEGRITY, CENTERS FOR MEDICAID SERVICES, DEPARTMENT OF 

HEALTH AND HUMAN SERVICES; LEONARD GUNDERSON, 

CHAIRMAN, BOARD OF DIRECTORS, AMERICAN SOCIETY 

FOR RADIATION ONCOLOGY; REBECCA SMITH–BINDMAN, 

PROFESSOR OF RADIOLOGY, EPIDEMIOLOGY/BIOSTATISTICS, OBSTETRICS, GYNECOLOGY, AND REPRODUCTIVE 

SCIENCES, UNIVERSITY OF CALIFORNIA, SAN FRANCISCO 

SCHOOL OF MEDICINE; AND SAL MARTINO, CHIEF EXECUTIVE OFFICER, AMERICAN SOCIETY OF RADIOLOGIC TECHNOLOGISTS 

Mr. PITTS. Mr. Spiegel, you are recognized for 5 minutes. 

STATEMENT OF JOHN SPIEGEL 

Mr. SPIEGEL. Thank you. Chairman Pitts, Ranking Member 

Pallone and members of the subcommittee, I am pleased to be here 

today to discuss the role of the Centers for Medicare and Medicaid 

Services and accrediting suppliers of advanced diagnostic imaging 

services. CMS is working to ensure that Medicare beneficiaries receive advanced diagnostic imaging services from suppliers that 

meet quality and safety standards. Section 135 of the Medicare Improvements for Patients and Providers Act of 2008, or MIPPA, requires that beginning January 1, 2012, Medicare can only make 

payments to the supplier of the technical component of advanced 

diagnostic imaging services if the supplier is accredited, including 

personnel standards, by an accrediting organization approved and 

designated by the Secretary of the Department of Health and 

Human Services. 

CMS has implemented these statutory provisions. This advanced 

diagnostic imaging accreditation requirement applies to MRI, CT, 

nuclear medicine, including PET. The law also gives the Secretary 

flexibility to expand the scope of the diagnostic imaging to which 

the imaging accreditation could apply, but the statute specifically 

excludes X-ray, ultrasound, and fluoroscopy procedures. 

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accredit advanced diagnostic imaging suppliers. By law, the accredVerDate Aug 31 2005 08:57 Nov 25, 2013 Jkt 037690 PO 00000 Frm 00040 Fmt 6633 Sfmt 6633 F:\112-15~1\112-15~1 WAYNE
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iting organizations must establish standards in specified areas, including qualifications of personnel performing advanced imaging 

services, qualifications of medical directors in supervising positions, 

procedures to ensure that the equipment used meets performance 

specifications, standards to ensure the safety of both beneficiaries 

and staff performing the imaging test, and quality assurance and 

control program to ensure the reliability of the diagnostic images. 

CMS selected three national accrediting organizations that meet 

all the standards and requirements prescribed in MIPPA: the 

American College of Radiology; the Intersocietal Accreditation 

Commission; and the Joint Commission. MIPPA provided that suppliers previously accredited by one of these approved accreditation 

organizations did not need to seek new accreditation to comply 

with the MIPPA requirements but must continue to maintain their 

accreditation. 

As of May 25 of this year, there are 15,821 accredited suppliers 

and a total of 61,434 locations, two-thirds of which are accredited 

by the American College of Radiology. The accrediting organizations designated by the Secretary have developed detailed standards that address the qualifications of individuals performing the 

technical component of advanced diagnostic imaging. Each accrediting organization has developed specific guidelines for staff performing different advanced diagnostic imaging modalities. For example, the ACR requires that radiologic technologists performing a 

CT be certified by the ARRT or have a State license, have documented training in CT, and complete various continuing education 

requirements. The other accrediting organizations have similar requirements or assurances. 

In States where there is a licensure or certification requirement, 

the accrediting organization standards include those State requirements. However, the accrediting organization’s personnel standards 

go beyond these minimum State requirements to include a range 

of standards that address different aspects of advanced diagnostic 

imaging. This assures that only technicians and technologists that 

meet the experience and education requirements established by the 

accrediting organizations are considered qualified personnel. 

CMS believes that the MIPPA accreditation provision strikes a 

careful balance by focusing oversight and attention on areas of imaging that pose the greatest risk to patients in a manner that minimizes the burden imposed on physicians and others who furnish 

imaging services. The exclusion of X-rays, fluoroscopy, and 

ultrasound from accreditation requirement limits burdens on individual physician practices, especially primary care physicians who 

may perform these tests in their offices. 

The use of accrediting organizations is required in MIPPA and 

enhances patient safety. This approach enhances patient safety 

without the need for additional direct Federal Government oversight of every supplier of advanced diagnostic imaging that serves 

Medicare beneficiaries. 

As physicians increasingly rely on advanced imaging services to 

diagnose complex medical conditions, the MIPPA accreditation requirement provides Medicare beneficiaries with assurances of imaging facilities with well-trained staff, using safe machines and 

procedures to conduct diagnostic imaging tests. 

38 

We will continue to work to fulfill our statutory requirements to 

oversee the accreditation process and ensure that accrediting organizations, suppliers, and beneficiaries continue to have the information they need on these requirements. Thank you and I would 

be happy to answer any questions. 

Mr. PITTS. The Chair thanks the gentleman. 

[The prepared statement of Mr. Spiegel follows:] 

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Mr. PITTS. Dr. Gunderson, you are recognized for 5 minutes for 

your summary. 

STATEMENT OF LEONARD GUNDERSON 

Mr. GUNDERSON. Chairman Pitts, Representative Pallone, and 

members of this distinguished committee, good morning and thank 

you for the opportunity to testify at today’s hearing. 

ASTRO and its over 10,000 members applaud the leadership of 

Representatives Whitfield and Barrow for sponsoring the CARE 

Act which has broad bipartisan support in this committee. ASTRO 

strongly supports immediate passage of the CARE Act which is a 

key component of our patient safety initiative. 

I am an emeritus professor and consultant in radiation oncology 

at Mayo Clinic where I have practiced for 28–1/2 years, 21 years 

in leadership positions. I am the chair of the ASTRO board of directors who I am representing today. I care deeply about my profession and the health and safety of our patients. 

It is important to note the marked difference in the use of radiation for treatment of cancer patients versus for diagnostic purposes. In diagnostic radiology, low doses of radiation are used for 

imaging studies to determine if problems exist. With radiation oncology, we use high-dose radiation to kill cancer cells, and we often 

find better results with higher doses. 

When a patient is diagnosed with cancer, a radiation oncologist 

discusses and agrees upon treatment options with the patient and 

their family. We plan and deliver that care with support from nonphysician members of the radiation oncology treatment team. This 

treatment team consists of a medical physicist responsible for quality assurance programs and making sure the equipment is working 

properly; a dosimetrist carefully develops a computerized plan in 

conjunction with the radiation oncologist to make sure the cancer 

gets the prescribed dose while nearby healthy tissues are spared; 

and a radiation therapist or technologist who administers daily radiation treatments under the physician’s supervision. 

ASTRO has long advocated for Congress to improve the safety of 

radiation therapy by establishing minimum education and 

credentialing standards. As you are aware, in some States, basic 

training standards are voluntary, allowing individuals to perform 

some radiation oncology procedures without any formal education. 

Without a minimum level of standards, patients are at risk. 

The CARE Act would set needed education and certification 

standards for radiation therapists, medical physicists, and medical 

dosimetrists who participate in the delivery of radiation therapy for 

Medicare patients. These minimum standards will help ensure that 

patients are treated accurately and safely, leading to reduced complications and potentially higher patient survival rates. 

We are concerned about proposals to expand MIPPA in lieu of 

proceeding with the CARE Act. As you know, MIPPA applies only 

to advanced diagnostic imaging services provided in freestanding 

centers, not radiation therapy services. If MIPPA were simply expanded to include radiation therapy services, we are concerned that 

the vast majority of radiation oncology patients won’t benefit because they are treated in hospital outpatient departments, not in 

freestanding centers. 

46 

While a critical step, we do not believe that the CARE Act alone 

can prevent medical errors that are possible in a complex treatment such as radiation therapy. That is why ASTRO is committed 

to working with Congress and this committee on additional efforts 

to ensure patient safety, particularly in the area of practice accreditation, which is different than credentialing the nonphysician members of the radiation oncology treatment team. The CARE Act is 

one of the many pathways toward increased patient safety. ASTRO 

has been a leader in efforts to improve the quality of care and patient safety and these initiatives are detailed in our written testimony. 

Finally, I want to conclude with a story of one of my patients 

that immediately came to mind when I was asked to testify. It involves a man diagnosed with metastatic terminal cancer that was 

not responding to chemotherapy. His dying wish was to walk his 

daughter down the aisle at her wedding. He needed, of course, radiation therapy to treat his metastatic cancer, relieve his pain, and 

hopefully prolong his life. Just before his first radiation treatment, 

one of our well-trained radiation therapists caught a computer 

error that if left unchecked would have resulted in a less-than-favorable outcome. We corrected his treatment plan and delivered a 

high-quality course of treatment. Although his cancer ultimately 

killed him, it was not before he achieved his wish of walking his 

daughter down the aisle. 

This story illustrates the importance of ensuring that every cancer patient is treated by a team that includes top-notch, highly 

trained and qualified individuals, which is why we need to pass the 

CARE Act. ASTRO wants patients to have peace of mind when it 

comes to safety, quality, and efficacy of radiation therapy. We urge 

the committee to immediately pass the CARE Act and we look forward to working with you on additional policies to further enhance 

the quality of care patients receive. Thank you again for the opportunity to testify, and I would be happy to answer any questions. 

Mr. PITTS. The Chair thanks the gentleman. 

[The prepared statement of Mr. Gunderson follows:] 

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Mr. PITTS. I now recognize Dr. Smith-Bindman for 5 minutes for 

an opening statement. 

STATEMENT OF REBECCA SMITH–BINDMAN 

Ms. SMITH-BINDMAN. Mr. Chairman, ranking member, and members of the subcommittee, thank you for this opportunity to testify 

today. I am Dr. Rebecca Smith-Bindman, a professor at the University of California, San Francisco School of Medicine. I am a clinical 

radiologist and I conduct research focused on assessing the risk 

and benefits of medical imaging. 

My testimony today focuses on CT because it is one of the most 

common imaging tests that we will use for medical diagnosis, and 

is also the test for the greatest potential for causing harm because 

of the amount of radiation it uses. CT uses X-rays to obtain extremely detailed images of internal organs, and the development of 

CT is widely considered among the most important advances of 

medicine. 

In part because it is so useful, the use of CT has increased dramatically over the last 15 years. Last year approximately 75 million CT scans were obtained and approximately 1 person in the 

U.S. per 10 obtained a CT. Although CT is useful it delivers much 

higher doses of radiation than do conventional X-rays, and exposure to radiation can cause cancer. 

To help put this into context, when you go to the dentist and you 

are offered dental X-rays, you may pause to consider the benefits 

as well as potential harms associated with getting X-rays. The 

most common type of CT scan that patients undergo in the U.S. delivers the same amount of radiation as approximately 1,500 or 

more dental X-rays. 

In other contexts, people have been concerned about the X-rays 

that are used at airports to screen passengers. One CT delivers the 

same amount of radiation as approximately 200,000 airport 

screenings. 

My research team at UCSF has conducted several research studies to assess the radiation dose patients receive when they undergo 

CT and we have found that for every type of CT scan patients undergo, the radiation doses are higher than most physicians are 

aware, and we have found tremendous variation in the doses between patients in the same facility. For example, one patient may 

receive a dose of radiation 20 times another, even at the same hospital and for exactly the same clinical problem. Put another way, 

if a patient goes to a facility to get a CT scan of her abdomen, she 

has no idea if she will receive a low dose or a high dose. And yet 

the patient who receives the higher dose study may be at risk 20 

times-fold of getting cancer for that examination while receiving no 

extra benefit from the radiation dose to which she was exposed. 

These differences in how much radiation are used for diagnostic 

CT is not accidental and yet these are not considered errors, but 

instead, I believe incorrectly, these are considered and labeled the 

‘‘art of medicine.’’ This sadly is more akin to Russian roulette than 

personalized health care. 

There are clear-cut cases of errors in the use of CT when the 

technologist delivers a dose vastly higher than intended. And when 

these kinds of errors are made, patients from diagnostic CT can be 

58 

exposed to doses that cause skin burns, hair loss, and severe damage to the tissue. Thousands of such cases have been reported and 

many of these errors have happened because of errors in how the 

technologist programmed the scanner. However, even when CT 

scanning is done correctly, patients who undergo CT—even a single 

CT—have an increased risk of cancer; and the higher dose of radiation to which they are exposed, the greater their risk. Since many 

patients who undergo CT undergo multiple scans, their risks are 

even higher. 

An important research paper was published yesterday in the 

Medical Journal of Atlanta, and that study directly showed that 

healthy children who were exposed to even a single CT were more 

likely to develop brain cancer and leukemia. Thus, doses we experience every day as part of routine CT are potentially dangerous. 

My research team has studied millions of individuals enrolled in 

large integrative health-care systems and we have found a large 

number of patients receive unnecessarily high doses of radiation 

because of repeated scanning with CT and because some CTs deliver higher doses than needed. Several people are involved when 

a CT scan is done. Radiologists order the scan and they select the 

protocol or set of instructions that should be used, but it is the 

technologist who does the study. 

The console of a modern CT scanner looks a lot like the control 

panel of a fighter plane, and it is not possible for the technologist 

to simply press a ‘‘low dose’’ button and generate the desired 

image. Instead, the technologist must make a large number of independent decisions and follow complex instructions on how to program each patient. Yet despite the complexity of the machines and 

the profound importance of what the technologist does, the technologist who conducts CT examinations receives little education on 

what doses are excessive, receive no consistent education on how 

to lower doses they deliver, and there are no consistent standards. 

In some States technologists receive only minimal on-the-job training. 

Further, because there are no uniform design standards, technologists have to scan patients on different machines that all work 

differently. As part of the research project I am leading to standardize dose, we have organized a large meeting that will be available to all, to be held in February of next year. While the meeting 

will target physicians, physicists, administrators, referring physicians, the primary focus is to educate and certify radiology technologists on how to understand and monitor and lower the doses 

to which they are exposed. 

There is a second and equally important problem that must be 

addressed, however, to improve the safety of CT. Radiologists determine how the test should be performed but there are few guidelines on what target doses are desirable. Each radiologist starts 

from scratch in creating these protocols at their institution. And 

while the general principle is that doses should be kept as low as 

reasonably achievable, there are few guidelines about what doses 

are reasonable or achievable. 

In order to improve the safety of CT, we need clear standards for 

what are acceptable levels of radiation for diagnostic CT. The doses 

used in clinical practice must be monitored. The National Quality 

59 

Forum, a leading organization that develops and endorses measures of health-care quality, has endorsed the measure to focus on 

CT. And if facilities follow this measure, they will quickly learn 

what they are doing and where they need to improve. 

Lastly, the dose should be reported in every patient’s medical 

record. California recently enacted a law that goes into effect in 

several months that requires this and provides a template for national legislation. There are a growing number of data monitoring 

software products that help facilities conduct the kind of dose assessment and monitoring that I have suggested, and ideally these 

dose-monitoring software products can be used and can be integrated with manufacturers and radiology information systems to 

help us work together to enable the electronic capture of patient 

dose information and inclusion of the information in the medical 

record. 

Lastly, oversight of CT is highly fragmented. The FDA oversees 

the approval of the CT scans but does not have regulatory oversight for how these machines are used in practice. Through 

MIPPA, CMS has an accreditation process in place that we heard 

about. Separately CMS’ other authorities to encourage the adoption 

of quality standards, such as those adopted by the National Quality 

Forum that could facilitate facility assessment, reporting, standardization of the radiation dose used for CT, and CMS should be incorporated to incorporate such quality measures in their systems. 

Mr. PITTS. Could you wrap up? 

Dr. SMITH-BINDMAN. Given the importance of CT and yet its potential for causing cancer, it is imperative we make CT scanning 

as safe as possible. These efforts must include education, certification of technologists, the creation of benchmarks, the requirement of recording and monitoring data, as well as a reduction in 

the necessary exams. 

Thank you for allowing me to participate in this discussion. 

Mr. PITTS. Thank you. 

[The prepared statement of Ms. Smith-Bindman follows:] 

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Mr. PITTS. Dr. Martino, you are recognized for 5 minutes for your 

summary. 

STATEMENT OF SAL MARTINO 

Mr. MARTINO. Chairman Pitts and members of the subcommittee, 

my name is Sal Martino and I am the chief executive officer of the 

American Society of Radiologic Technologists. I am also a registered radiologic technologist myself. On behalf of ASRT’s 146,000 

members, thank you for calling this hearing to examine why we 

must establish standards for medical imaging and radiation therapy technologists. 

These individuals perform procedures that are critical to accurately diagnosing and treating millions of Americans each year, 

from the X-ray that monitors the lungs of a premature infant to the 

radiation therapy that extends the life of a grandmother fighting 

cancer. Because these procedures expose patients to powerful doses 

of radiation, most of us assume that everyone who performs them 

is competent and educated. But the truth is, unqualified personnel 

examine and treat thousands of patients every day. That is because 

Washington, DC, and 11 States do not regulate radiographers, 15 

States do not regulate radiation therapists, and 20 States do not 

regulate nuclear medicine technologists. 

In States without regulations, people are allowed to expose patients to potentially dangerous levels of radiation after just a few 

weeks of on-the-job training. And even in States where personnel 

are regulated, laws vary widely. 

Unqualified personnel represent a serious health risk to the 

American public. Fortunately, a solution is within reach. The Consistency, Accuracy, Responsibility, and Excellence in Medical Imaging and Radiation Therapy bill, known as the CARE bill, asks the 

Federal Government to establish standards for technical personnel 

in the radiologic sciences. 

Under the CARE bill, anyone who performs medical imaging or 

delivers radiation therapy would be required to graduate from a 

formal educational program in the field. They also would have to 

pass a national certification exam that tests their understanding of 

radiation protection and patient care techniques. And finally, they 

would be required to obtain continuing education throughout their 

careers, ensuring that they remain proficient. 

Many of you are familiar with the CARE bill. It was first introduced in the 106th session of Congress in 2000 and it has been introduced in every session since then. In 2006, the Senate passed 

the bill by unanimous consent, but the session ended before the 

House could take action. 

The current version of the CARE bill, H.R. 2104, has more than 

120 bipartisan cosponsors in the House of Representatives. It also 

has the support of dozens of health-care and patient advocacy organizations that represent millions of Americans. 

Together we support the CARE bill for three important reasons: 

First, the CARE bill will improve quality. The accuracy of any 

radiologic procedure depends on the skill of the person performing 

it. An X-ray won’t reveal a broken bone and a CT won’t find a 

growing tumor if the person using the equipment doesn’t know the 

basics of anatomy, exposure, and technique. Accurate exams lead 

75 

to diagnosis, treatment, and cure. Poor-quality exams lead to additional testing, delays in treatment, and unnecessary anxiety for patients. Even worse, they may cause a misdiagnosis that has tragic 

consequences. Radiologic technologists must be properly educated 

to perform their work accurately. 

Second, the CARE bill will improve safety. Medical radiation 

comes with risks. Overexposure can cause skin burns, lead to the 

development of cancer, and cause birth defects in future generations. CT scanners, gamma cameras, and linear accelerators are 

some of the most complex technology in the medical field, and patients could be injured or even killed if this equipment is not used 

properly. Educated technologists know how to properly administer 

radiation, position patients, and shield organs to deliver the lowest 

possible dose. 

And third, the CARE bill will reduce health-care costs. More 

than 300 million medical imaging procedures are performed in the 

United States every year. Unfortunately, thousands of these exams 

have to be repeated every day because unqualified personnel made 

positioning or exposure errors. The Federal Government pays for 

many of those mistakes. Medicare spent approximately $11.8 billion on medical imaging in 2009. If we can reduce the number of 

repeated exams by just 1 percent, Medicare would save more than 

$100 million a year. 

In an era when difficult budget decisions must be made, the 

CARE bill makes good fiscal sense. The best way to ensure the 

quality, improve the safety, and reduce the cost of radiologic procedures is to establish standards for personnel who perform them. 

For the past 12 years, that has been the straightforward goal of the 

CARE bill. It is time to pass this important piece of legislation. 

Your support for the CARE bill shows your support for America’s 

patients. Thank you. 

[The prepared statement of Mr. Martino follows:] 

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Mr. PITTS. The Chair thanks the gentleman and thanks all the 

panel for your testimony. We will now begin questioning. The 

Chair recognizes himself for 5 minutes for that purpose. 

Mr. Spiegel, we will begin with you. Can you tell us why MIPPA 

does not include imaging services that are done in the hospital setting? It seems to me that patients in the hospital would be at the 

same risk of harm as any other patient if these services are performed by personnel that are not adequately trained. 

Mr. SPIEGEL. I wasn’t employed at CMS at the time the bill was 

enacted, but the provisions of the statute don’t address advanced 

diagnostic imaging in a hospital setting. We implemented the provisions that were enacted in the MIPPA statute. 

Mr. PITTS. Would it be appropriate to address this issue by an 

expansion of MIPPA? 

Mr. SPIEGEL. I am really not in a position to say whether or not 

hospital radiology needs to be addressed apart from MIPPA or 

some other way. I know CMS has in place hospital conditions or 

participation that address requirements for imaging in a hospital 

setting and we enforce them. 

Mr. PITTS. Dr. Smith-Bindman, an individual patient in discussion with their doctor may be willing to be exposed to increased 

risk for radiation exposure in order to diagnose or treat their cancer. Do you think that if we err on the side of overregulation by, 

for example, instituting rigid guidelines that we run the risk of inhibiting patients’ care and possibly exposing providers of these 

services to liability? 

Ms. SMITH-BINDMAN. I think that you mentioned two things. I 

think, first, we need to have those discussions between patients 

and providers that acknowledge there are risks and benefits of 

medical imaging. So first those discussions have to happen. 

Second, if we can encourage facilities to start to look at the doses 

that they use, they can lower those doses, literally overnight. And 

so part of what I am encouraging is both looking at doses and then 

not imposing rigid standards on how to lower, them but just requiring facilities look at how they are doing. And just looking at how 

they are doing, I have had experience at a large number of facilities, has led to an overnight reduction in doses for patients who get 

very high doses. 

Mr. PITTS. Dr. Martino, or any of you, what question should patients ask the technologist or the radiologist before getting an imaging exam? And what questions should they ask the referring 

physician before going forward with an exam? 

Mr. MARTINO. Well, the first question they would ask—and if I 

took my granddaughter in for an X-ray, the first question I would 

ask is, are you a certified radiologic technologist? And if they were 

not, I would not let them take my X-ray or that of my granddaughter. So that is the number one fundamental question for me. 

Ms. SMITH-BINDMAN. I think going back a step, anytime advanced imaging is ordered, a patient should ask their physician if 

it is absolutely necessary. Do I need this test? Do I need this test 

now? Or can I wait to have this test? Can I have another test that 

may help? Or if I do need this test, is it possible to have a test that 

does not use ionizing radiation? 

81 

And now we are so enamored with testing that often patients 

begin that discussion wanting the test, without appreciating that 

there are choices to be made and that there are both risks and benefits. 

So first I decide, do I actually need to go forward? And then if 

they go forward, I think the more patients that ask their physicians and their technologist, can you tell me what kind of radiation 

dose I am going to be getting from this test will really encourage 

the technologists and providers to look at their own data so they 

can provide really informed information. 

Mr. PITTS. Thank you. Dr. Gunderson, could you tell us why this 

is an issue that needs legislation rather than something that could 

come from within the medical societies or State level boards? 

Dr. GUNDERSON. Radiation oncology societies can certainly make 

recommendations to individuals as far as whether certification 

should exist. And we certainly do do this. But that does not require 

our members to listen to what we say and to carry it out. 

So I think there is an absolute need to have the CARE Act 

passed so that it does put in place minimum standards. I think of 

this as a foundation for building further with regard to safety 

issues as putting in place the minimum standards that are required by the CARE Act which societies can encourage but certainly cannot enforce in any way. 

Mr. PITTS. I just have 10 seconds. Dr. Martino, is there any benefit to State flexibility with regard to technician licensing? I assume that the availability of accredited schools varies. Might 

States with many health professional shortage areas lose out if unlicensed technicians can no longer practice? 

Mr. MARTINO. No. There are more than adequate radiologic technology programs throughout the country. Even in rural areas. And 

the CARE bill also does have provisions to phase in and allow 

those individuals to get the additional education that they would 

need to become certified. 

Mr. PITTS. My time has expired. The Chair recognizes the ranking member for 5 minutes for questions. 

Mr. PALLONE. Thank you, Mr. Chairman. I was going to start 

with Dr. Gunderson. 

In your testimony you describe differences between diagnostic 

imaging and radiation therapy. And I wondered if you would elaborate on those differences and tell us more about the varying safety 

considerations and how might the education and training of radiation therapists differ. 

Dr. GUNDERSON. With regard to the marked differences between 

diagnostic radiology and radiation oncology, as I mentioned, diagnostic radiology uses much lower doses of radiation, primarily for 

imaging purposes to determine if problems exist, and they are exceedingly helpful to a radiation oncologist with CT imaging or an 

MRI to say, here is where the cancer is and here is where we need 

to focus upon. 

In radiation oncology we use much higher dose levels of the radiation, but dose alone is not the thing that one needs to think about. 

We use much higher doses, where if we are treating with radiation 

alone, we are going to be delivering often a series of 30 to 40 treatments over a time period of 7 to 8 weeks, treating 5 days a week. 

82 

And dose alone is—total dose becomes important, what the dose 

per fraction is, and whether we are using it with curative intent 

or intent to try to totally kill the cancer versus with palliative intent. 

What are we doing with regard to patient safety issues? We are 

very delighted with the provisions that were put into the Patient 

Safety Act in the mid-2000s with regard to the ability to collect information on medical errors or near misses without there being 

legal ramifications. We have, in fact, begun a process of contracting 

with an existing patient safety organization to launch the first radiation oncology error reporting system. 

As I noted, we believe the confidentiality provisions provided by 

the Patient Safety Act are going to ensure that accurate data is 

submitted and will also mean better participation from radiation 

oncologists throughout the United States. We think that contracting with a PSO will allow us to meet our goal of collecting radiation oncology patient safety data, analyzing it to improve the 

safety of radiation oncology, being able to do root-cause analyses, 

and pass that information along to our membership in appropriate 

ways so that they can learn from it and apply those things in their 

own practices. And we expect the patient safety organization to be 

functioning by the end of 2012. 

Also in our written testimony we talked about things that we 

have done starting—and expanding on in 2010. Patient safety has 

always been an important issue in radiation oncology. But with the 

2010 incidents, we did a 360 look. We put forward the ‘‘Target 

Safely’’ plan which is discussed in some detail in pages 6 to 8 of 

the written testimony with regard to working with industry to have 

standardization of talking across different systems from different 

providers. We call it the IHE–RO program where if we buy one 

thing from one provider of equipment versus another, that they 

will talk to one another and that there won’t be errors in that. We 

are interested in practice accreditation. We have written a series 

of white papers. 

So there are a number of things that we are doing that are outlined in there. And we feel strongly and we will continue to discuss 

these with our members and to work carefully with this committee 

and Congress in trying to improve patient safety. 

Mr. PALLONE. Well, thank you, Doctor. I appreciate that. 

I wanted to ask Dr. Smith-Bindman, you testified that 

credentialing of the personnel who position patients and administer 

radiation consistent with the goals of the CARE Act is an essential 

first step in improving the safety and quality of CARE. That is correct? 

Ms. SMITH-BINDMAN. Yes. 

Mr. PALLONE. OK. You also mentioned the importance of other 

strategies to improve safety and quality, such as the development 

and adoption of additional clinical guidelines, capture of info on the 

doses that patients receive, and documentation of dose information 

in the patient’s medical records. 

I want to focus on the tracking and documenting of the radiation 

dose a patient receives and the quality measure you mentioned. 

Can you explain why you believe that the adoption of the National 

Quality Forum-endorsed CT quality measures in clinical practice or 

83 

one with similar goals would improve the safety and quality of 

CARE? 

Ms. SMITH-BINDMAN. I think radiologists really want to do the 

best job that they can. And most radiologists understand that that 

means lowering the doses, keep them within a very narrow range. 

But unfortunately, most radiologists currently have no idea of the 

doses to which their patients are exposed. So if a patient goes to 

a facility and says, Doctor, can you tell me how much radiation I 

got on that exam or how much am I likely to get, or what kind of 

doses do you usually give your patients who undergo abdominal— 

an abdominal CT, most physicians and most facilities would have 

no way to answer that question. 

So by adopting the quality measure, facilities are asked to summarize the doses they are using. What is the average dose for an 

abdominal CT? And that would quickly allow facilities to see how 

they are doing. 

And as I mentioned, I have worked with a large number of facilities. And for each of those, the first step of us showing them their 

data has been surprise that the doses have been so high. And the 

second step has been to figure out how to lower them. And it is not 

so difficult to lower them once you figure out the problem. So if patients in general are being imaged for a larger area, well, then you 

image a smaller area. If patients undergo four scans of their chest 

and that leads to higher doses, well maybe you want to reduce that 

to one. So I think it is a way to just allow facilities to see how they 

are doing, to start having standard metrics so all facilities start 

using the same words to describe dose and use the same standards 

against which they are assessing their quality and performance. 

Mr. PALLONE. Thanks a lot. Thank you, Mr. Chairman. 

Mr. PITTS. The Chair thanks the gentleman. 

We are in a series of votes that are going to last past the noon 

hour. We will take one more line of questioning from the vice chairman, Dr. Burgess, for 5 minutes before we break. 

Mr. BURGESS. My question is: Why do we have so many votes 

that are going to take us past the noon hour, Mr. Chairman? Who 

thought that was a good idea? 

Well, Dr. Spiegel, I just have to tell you, you struck a chord with 

me with your discussion, perhaps not entirely in the confines of 

what we are considering on the committee today. But I practiced 

OB/GYN for 25 years back in Texas and I recognize that, just like 

you, you recommend the test or a procedure to a patient, and the 

next question is generally not is it safe, is it necessary? We 

wouldn’t even get down to the detail of how much radiation to 

which I would be exposed. But it is, Does my insurance cover it? 

And if my insurance covers it, suddenly the curiosity drops right 

off. 

And perhaps one of the failings of the third-party payment system that we have developed and why I believe so much in a consumer-directed health care and health savings account is that you 

have to get the patient back into this equation. And the money is 

one way to do it. And as a consequence of the patient being in 

charge of the money, perhaps even the questions about the radiation safety or the dosage might be something that is introduced 

back into the conversation. 

84 

So I appreciate very much your observation on that. And I will 

just tell you, I am sure it is happening hundreds of times this very 

morning, where a radiological procedure is being recommended. 

And the patient is anesthetized and the doctor also may be anesthetized as well, except in our specialty, in OB/GYN, when a pregnant woman inadvertently gets an IVP, then suddenly everybody 

is concerned about what the dose of radiation was that was involved in that study. And then we go into great detail to try to figure it out. 

Do you have any other observations on that? Because that was 

a particularly powerful statement that you made. 

Ms. SMITH-BINDMAN. I mean, in addition to being an academic, 

I am a parent who has three children. And I have been in many 

circumstances where imaging with radiation is advised to my children. And in those circumstances, I want to know the risks and 

benefits to my child of that exam. And I try very hard to go in not 

as a radiologist but to go in as a mom. When my youngest fell out 

of a tree and had a CT scan, that seemed like the right thing to 

do. He did a head-dive out of a cherry tree. 

Mr. BURGESS. That was your son, correct? Not your daughter? 

Ms. SMITH-BINDMAN. That was my son. Only the CTs of the head 

are my son’s. 

But last year, he had a very small fall, skiing; and I couldn’t get 

ahold of my husband and I took him to the emergency department. 

And the emergency department physician told me later that from 

across the room he could see that my son had a concussion, but 

knew for sure he didn’t have a bleed. And I went in very open. If 

he needs a CT, he needs it. If not, I am not going to influence his 

decision. And the ED doctor said, if you want a CT, I am happy 

to do it, but I don’t think he needs it. So I was very happy with 

that decision. 

And partly what I do when I educate technologists and radiologists is to think of every patient as if it is your own family member 

and use all the information to decide whether it is necessary: the 

value of the test, the effectiveness, the risks. And then I agree with 

you, I think the payment piece has disappeared from our consideration, but it is a very important issue. 

DMr. BURGESS. Thank you. 

Dr. Martino, I need to ask you—again, this is a bit off topic, too. 

But the dosage of radiation that we get when we walk through that 

TSA scanner at the airport, is that a significant source of radiation 

for people? 

Mr. MARTINO. All radiation is not good, but we have it in the environment and wherever. I believe that those are low enough that 

I don’t worry about that. 

Mr. BURGESS. Bear in mind that you are talking to a panel of 

frequent flyers here. Anyone who lives west of the Mississippi is 

probably higher on the dosage chart. 

Mr. MARTINO. Myself also. But it is so low down compared to 

what medical radiation is in terms of the individuals that are giving those doses to patients. 

Mr. BURGESS. Well, I will tell you why I was concerned about 

this. Several years ago in the transportation bill, I tried to get language in addressing the radiation exposure to flight crews. You 

85 

know, the solar activity varies from time to time. And this is information that is available but not generally dispensed to the airlines, 

such that they might select a different flight route or altitude because of solar activity and solar radiation that might be emanating 

that day. 

So you are right. We have got it in our environment all the time. 

And as a consequence, any is possibly dangerous, so why wouldn’t 

we do the things necessary to minimize that? I was a little taken 

aback when we developed these back-scatter imaging devices, you 

know, to catch the bad folks. But at the same time you are putting 

a lot of innocents through this device. And for those of us up on 

the dais here, that is twice a week, 35 weeks a year. 

Mr. MARTINO. Myself included. I would add though, I think anyone who has anything to do with any kind of equipment that dispenses radiation, even the low doses, say, in an airport scanner, 

should have some kind of minimum knowledge and understanding 

about what it is they are operating. And if there was an error— 

I mean, it could be a simple hour course for the TSA scanners, that 

they understand. 

Mr. BURGESS. Are they certified in any way as far as radiation 

understanding? 

Mr. MARTINO. No, not that I am aware of. 

Mr. BURGESS. Did the FDA get involved in this? Because they 

can be pretty tough on medical devices. 

Mr. MARTINO. I deal with the certification of those individuals 

that are dispensing radiation for medical purposes. 

Mr. BURGESS. Thank you, Chairman. I will yield back. Thank 

you. 

Mr. PITTS. The Chair thanks the gentleman. We are in the middle of a series of votes. There are about 5 minutes left on the first 

vote. We will recess until about 5 minutes after the last vote, which 

will be around 12:15, I am told. So we ask for your patience. At 

this time, the subcommittee stands in recess. 

[Recess.] 

Mr. PITTS. The time for recess having expired, we will reconvene, 

and we have finished the first round of questioning. We will go to 

follow-up with Dr. Burgess for 5 minutes for questions. 

Mr. BURGESS. Thank you, Mr. Chairman. Dr. Gunderson and Dr. 

Martino, if I could ask you, do you think if we put in place a Federal minimum standard for accreditation for technologists that it 

will restrict entry into that field and we are going to end up with 

difficulty filling those positions? 

Dr. Gunderson, if you will go first, and Dr. Martino. 

Mr. GUNDERSON. At the present time, the main issue I think 

with certification programs and training programs for radiation 

therapy technologists is the fact that we may not currently have 

enough training programs that exist out in the real world, and part 

of that is because some of the programs have contracted instead of 

expanded. 

And when I moved from Mayo Clinic in Rochester, Minnesota, 

down to Mayo Clinic in Arizona, we were surprised to find that 

there were no training programs for radiation therapists in Arizona, and so we actually worked together with the radiation oncology practices in Arizona and with the community college and actuVerDate Aug 31 2005 08:57 Nov 25, 2013 Jkt 037690 PO 00000 Frm 00089 Fmt 6633 Sfmt 6633 F:\112-15~1\112-15~1 WAYNE
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ally set up a program which actually required the institutions putting in some financial support because the community college 

wasn’t willing to take that on themselves upfront. And so we felt 

strongly enough about the need for a training program with radiation oncology technologists that we convinced our colleagues in 

what ended up being competing institutions to say the need exists, 

let’s work together and make sure this happens. And that program 

has stayed as a continuous program ever since that time, so that 

will be one of the issues, just making sure there are—— 

Mr. BURGESS. Just to be sure, did those programs result in certification of those students who completed the requirements? 

Mr. GUNDERSON. They did. They would have progressed through 

the training and gone to certification. But it is an issue, and that 

is why once the CARE Act is passed, we will have to be careful to 

phase in some of these things so that if there aren’t programs that 

exist in certain States, that one has time to put those programs 

into place and allow them to function. In my mind it will not prevent people from going into the field, because it is a very attractive 

field, and we have not had any problem at all filling the positions 

in the school that we created in Arizona, for example. 

Mr. BURGESS. Very well. Dr. Martino, you may have actually answered that before we went to break, but your thoughts on that? 

Mr. MARTINO. ASRT has a significant research department, and 

we do a lot of research and publish research. Every year we do an 

enrollment survey to see what the enrollment in the educational 

programs are throughout the country, both in medical imaging and 

radiation therapy. Right now, in fact, there is a bit of an oversupply of medical imaging technologists, and students have waiting 

lists in most community colleges and are—— 

Mr. BURGESS. If I could interrupt you for just a minute. What 

about the geographic distribution, though; are there areas in the 

country where it would be more of a challenge to fill those positions? 

Mr. MARTINO. Not right now. Yes, of course, you have, you know, 

more programs in some of the urban areas, but even in the rural 

and suburban areas, community colleges are very interested in 

these kinds of programs because they lead to employment when 

students get out of school. They have also now raised the requirements; starting in 2016, you are going to need an associate’s degree 

to enter the field. So many community college programs are now 

opening. So we don’t really expect there to be that much of a shortage in radiography. 

Radiation therapy, right now there is only a 4–1/2 percent vacancy rate in radiation therapist positions. Dr. Gunderson is right, 

it is somewhat regional. There are a couple of States that don’t 

have radiation therapy programs, but there are a couple of radiation therapy programs coming online. But our—both our workplace surveys and our enrollment surveys show that there is more 

than enough of supply right now to meet demand and that many 

of the programs, like nursing programs, have waiting lists to get 

in because students are realizing that they want to go to college 

and get a job when they get out, and health care is a really expanding area. And in any places where there might be a problem, there 

87 

is a phase-in period for the CARE bill, so there should be enough 

time for supply to meet demand. 

Mr. BURGESS. Very well. You know, remembering the passage of 

MIPPA in the summer of 2008, it was July of 2008, and we have 

had another hearing in this committee on this issue back in 2010, 

and I think Chairman Pallone led that hearing, and we are very 

grateful to him for doing that, but I am hard pressed to recall a 

hearing on this subject prior to the passage of MIPPA. 

I have only been on the committee since 2004, so staff may correct me that there have in fact been other hearings, but it is a fairly significant and fairly complex issue, and when MIPPA passed, 

for those of you familiar with the Doc Fix, this was the passage of 

the Doc Fix. It came up on suspension rather rapidly one summer 

morning, and nobody ever wants to vote against the Doc Fix, myself included, because the docs always get mad if you do. 

But there were all these other ancillary policies that were then 

cobbled together and thrown on this so-called MIPPA bill, and I 

think it is just a cautionary tale for us here on this side of the 

hearing room that we must be careful when we take these things 

on, because they do have far-reaching, real-world consequences 

that affect people in very profound ways, both positively and negatively. And I wish we had taken the time to study this issue a little 

bit more before the leadership at that time put it onto that bill that 

came up rather hastily on the House floor in order to make a political statement and cause a stir in the then-Presidential campaign 

in 2008. 

Mr. Chairman, thank you for the indulgence, and I will yield 

back. 

Mr. PITTS. The Chair thanks the gentleman. For follow-up for 5 

minutes, the ranking member, Mr. Pallone. 

Mr. PALLONE. Thank you. I just have a brief question because I 

didn’t get to ask it before of Dr. Gunderson. It was clear from your 

testimony that you believe credentialing for technologists will do a 

great deal to improve patient safety. But can you elaborate on why 

ASTRO believes that additional patient quality and safety activities are an important complement to the goals of the CARE Act? 

Mr. GUNDERSON. Rephrase your question? 

Mr. PALLONE. Sure. You said that you believe—or at least I 

thought from your testimony—you believe that credentialing for 

technologists would do a lot to improve patient safety. So I just 

wanted you to tell me why you believe that, you know, that that 

is true, why additional quality and safety activities are important 

to the goal of, you know, the CARE Act, which is the bill that—— 

Mr. GUNDERSON. We believe it is important for the three components of the treatment team beyond the physician—the medical 

physicist, the medical dosimetrist, as well as the therapist/technologist. And if you think of a machine with gears that mesh together, if we have two members of that treatment team that have 

education and training but the third person doesn’t, then things 

can fall out of phase and things won’t work as smoothly as they 

need to work. 

So while the plans that we put in place for radiation therapy are 

a combination of interactions between the radiation oncologist and 

the dosimetrist where the radiation oncologist uses a CAT scan or 

88 

MRA to see here is where the cancer is, here is where the lymph 

node areas are that are at risk, and we contour that, and we also 

help contour the normal tissues and the healthy tissues that we 

want to spare. That information then is put into place by hopefully 

a trained dosimetrist who can integrate that and say, ‘‘OK, I am 

going to put my radiation beams in through all of these angles and 

put them in place so we can encompass the tumor and protect the 

normal tissues.’’ 

That information is then passed on to the therapist on the treatment machine, and as Representative Burgess I think talked about 

previously, if you have somebody that doesn’t have the training to 

make sure that the machine is turned on properly, to make sure 

the patient is positioned properly, then all of the work done by the 

radiation oncologist and dosimetrist comes to naught. So this is 

why we feel there needs to be minimum standards for all components. 

The physicist is the one that supervises the whole—if you want 

to call it—the safety team beyond the M.D. To make sure everything is running properly, and so he is at the top of that safety 

chain from the treatment team perspective along with the radiation 

oncologist. But if the dosimetrist and therapist don’t understand 

what they are doing, then what we envision happening with our— 

with the safety and care of our patients isn’t going to come to pass. 

And that is why we support the CARE Act for all three components, the physicist, the dosimetrist, and the therapist having adequate training and adequate certification, and why we strongly 

support the CARE Act. 

Mr. PALLONE. All right, thanks a lot, and thank you, Mr. Chairman. 

Mr. PITTS. The Chair thanks the gentleman. I will remind all 

members of the subcommittee who were unable to attend or return 

to the hearing that they may submit their questions in writing. 

They have 10 business days to submit questions for the record. 

I ask the witnesses to respond to their questions promptly, and 

I would like to thank the excellent panel we had today for the information they have shared with us. Members should, by the way, 

submit their questions by the close of business on Friday, June 

22nd. Without objection, the subcommittee is adjourned. 

[Whereupon, at 12:30 p.m., the subcommittee was adjourned.] 

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